BRIEF REPORT
Prevalence of Frailty and Associated Factors in the CommunityDwelling Population of China Lina Ma, MD, PhD,*† Zhe Tang, MD,* Li Zhang, MD,† Fei Sun, MD,* Yun Li, MD, PhD,† and Piu Chan, MD, PhD†‡
BACKGROUND/OBJECTIVES: Frailty in older adults predicts dependence and mortality and is a major challenge for healthcare systems in countries with rapidly aging populations. Little is known about frailty in China. We investigated the prevalence and associated risk factors of frailty in older adults in China. DESIGN: Cross-sectional. SETTING: Data were obtained from the China Comprehensive Geriatric Assessment Study, conducted in 2011–12, which was the first uniform comprehensive assessment system adopted in China. PARTICIPANTS: Older adults from 7 cities were selected based on well-established cluster, stratification, and random selection statistical sampling techniques (N = 5,844). MEASUREMENTS: The Comprehensive Geriatric Assessment-Frailty Index was measured based on demographic characteristics, physical health, physical function, living behavior and social function, mental health, and cognitive function. RESULTS: The overall weighted prevalence of frailty was 9.9%: 12.7% in southwestern China, 11.0% in northern China, 5.9% in northwestern China, 5.0% in southcentral China, 2.5% in eastern China, and 2.3% in northeastern China. The prevalence of frailty increased with age and was significantly higher in women and those living in rural areas. After adjusting for sex, age, area, region, and education, activity of daily living impairment was the strongest risk factor for frailty. Chronic diseases,
From the *Beijing Geriatric Healthcare Center, Xuanwu Hospital, Capital Medical University, Beijing Institute of Geriatrics, Key Laboratory on Neurodegenerative Disease of Ministry of Education, Beijing Institute for Brain Disorders; †Department of Geriatrics, Xuanwu Hospital, Capital Medical University, China National Clinical Research Center for Geriatric Medicine; and ‡Department of Neurology and Neurobiology, Xuanwu Hospital, Capital Medical University, Beijing, China. Address correspondence to Zhe Tang, Beijing Geriatric Healthcare Center, Xuanwu Hospital, Capital Medical University, Beijing Institute of Geriatrics, Key Laboratory on Neurodegenerative Disease of Ministry of Education, Beijing Institute for Brain Disorders, China National Clinical Research Center for Geriatric Medicine, Beijing 100053, China. E-mail address:
[email protected] DOI: 10.1111/jgs.15214
JAGS 2017 © 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society
depression, poor lifestyle, and geriatric syndromes were also independent risk factors. CONCLUSION: Our study provides epidemiological characteristics and the risk factors of frailty in China; the findings indicate greater regional disparities. Efforts to promote physical, psychological, and social health in older adults are a core objective of health policy, especially in women and those living in rural areas. J Am Geriatr Soc 2017.
Key words: frailty; geriatric assessment; epidemiology
F
railty is a multidimensional condition that increases vulnerability to stressors, is associated with risk of adverse health outcomes and mortality, and reduces quality of life of older adults,1 making it one of the greatest challenges for health care in an aging society. Frailty is the most common cause of death in community-dwelling older people,2 so its identification is clinically important. Moreover, frailty can be prevented or reversed if detected early through multicomponent interventions such as exercise and nutrition and could be predictive of adverse outcomes. With the increasing body of evidence of the risk factors of frailty that may influence well-being, the need for frailty screening tools to develop beneficial interventions is crucial. There are several diagnostic definitions of frailty, and two of them, the frailty phenotype and the Frailty Index (FI), have provided the conceptual basis to measure frailty. In 2001, Fried proposed the landmark frailty phenotype, which assessed frailty by measuring five physical components.3 The Fried phenotype has been the most commonly used assessment, but cultural and ethnic differences in frailty thresholds were identified for different populations. The FI is based on a number of accumulated health deficits4 and has stronger predictive power for mortality than the individual components; moreover, the FI is recommended as a valid, reproducible approach for measuring frailty in population datasets.5 The Comprehensive Geriatric Assessment (CGA) is a recommended component of the care of older adults and assesses socioenvironmental
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factors, physical health, physical function, and psychological status. The CGA-FI can be used to identify frailty in clinical conditions in individuals who are suspected of being frail6 and is suitable for the assessment of anyone with available CGA data. Although there is a preponderance of literature on frailty in developed countries, little is known about frailty in China, which has the largest aging population. Moreover, a systematic review identified the need for further validation of frailty screening tools in developing countries.7 We previously reported the prevalence of frailty to be 9.1% in Beijing,8 and we developed a 68-item frailty index, which proved to be a useful tool for prediction of prognosis9 and can be extracted from CGA data. This study aimed to investigate the prevalence of frailty and associated factors in the community-dwelling older adults in China based on the CGA-FI.
METHODS Participants Data were obtained from the China Comprehensive Geriatric Assessment Study (CCGAS; 2011–12), which was the first uniform nationwide CGA study in China. Based on well-established cluster, stratification, and random selection statistical sampling techniques, 7 cities from 7 provinces were chosen to represent 6 main regions in China: northern (Beijing), south-central (Changsha), eastern (Shanghai), northwestern (Xi’an), southwestern (Chongqing and Chengdu), and northeastern (Harbin) (Figure S1). Further details regarding the CCGAS have been previously reported.10,11 In total, 6,867 older adults were included, of whom 5,844 had complete CGA-FI data. There were no differences in sex, living area, education, or marital status between individuals included in the analysis and those excluded except for age (Supplementary Table S1). All study participants provided informed consent, and the ethics review board of Xuanwu Hospital approved the study design.
Frailty Criteria The CGA-FI was measured on the basis of six variables: demographic characteristics, physical health, physical function, living behavior and social function, mental health, and cognitive function.9 The FI score was defined as the cumulative sum of the total score of each index divided by 68. A score of 0.25 or greater was considered to indicate frailty.
Medical Conditions The following medical conditions were recorded: selfreported history of chronic disease diagnosed by a doctor, clinical syndromes, and geriatric syndromes. Activities of daily living (ADLs) and instrumental activities of daily living (IADLs) were also assessed. Impairment in ADLs was defined as impairment in any ADL; participants with ADL and IADL impairment were included in the ADL impairment group. Neuropsychological health was evaluated using the Geriatric Depression Scale (GDS) and Mini-
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Mental State Examination. Depression was defined as a GDS score of 11 or greater.
Statistical Methods A group of applications used in combination for creating documented data structures and analysis of quantitative data (EpiData, www.EpiData.dk) was used to establish the database. Results were presented as means and standard deviations for continuous variables and percentages for discrete variables. Weighted rates were calculated using the national standard population composition ratio based on the Sixth National Census (2010). Statistical analyses were performed using SPSS version 11.5 (SPSS, Inc., Chicago, IL). Chi-square tests were used to compare percentages; t-tests were used to compare means between groups. Forward stepwise logistic regression was used to calculate adjusted odds ratios. P < .05 was considered statistically significant.
RESULTS Demographic Characteristics The total population included 5,844 older adults, of whom 678 were frail, yielding an overall weighted prevalence of frailty of 9.9% based on the Sixth National Census. The prevalence of frailty was significantly higher in women (12.1%) than in men (7.7%). The prevalence of frailty in older adults in rural areas (12.9%) was significantly higher than in urban areas (7.8%). The prevalence of frailty increased with age, with the highest prevalence observed in individuals aged 80 and older (26.0%) and the lowest prevalence in those aged 60 to 64 (4.3%) (Table 1).
Prevalence of Frailty in Different Regions of China We observed significant differences in the prevalence of frailty between the 6 regions evaluated: 12.7% in southwestern China, 11.0% in northern China, 5.9% in northwestern China, 5.0% in south-central China, 2.5% in eastern China, and 2.3% in northeastern China (Supplementary Figure S2), but when we combined the 6 regions into 2 major parts, southern China (southwest, east, southcentral) and northern China (north, northwest, northeast), there was no statistically significant difference (Table 1).
Prevalence of Frailty According to Geography, Sex, and Age In urban areas, the prevalence of frailty differed significantly between the 6 regions, with northern urban regions having the highest rates and northeastern urban regions the lowest: 9.0% in northern China, 8.0% in eastern China, 8.8% in southwestern China, 6.0% in northwestern China, 5.0% in south-central China, and 2.3% in northeast China (Supplementary Figure S3A). Older adults living in rural areas included those residing in Beijing rural and Chengdu rural (representative of north and south China, respectively), and there was no significant difference in the prevalence of frailty between them (Supplementary Figure S3B). The prevalence of frailty in the six regions was
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Table 1. Prevalence of Frailty in Older Adults According to Sex, Area, and Age Total Characteristic
Total Sex Male Female Area Urban Rural Region North South Age 60–64 65–69 70–74 75–79 ≥80
Robust
n
Frail n (%)
Weighted, % (Frail)
Chi-Square
P-Value
5,844
5,166 (88.4)
678 (11.6)
9.9
2,529 3,315
2,282 (90.2) 2,884 (87.0)
247 (9.8) 431 (13.0)
7.7 12.1
14.64
